Plate Holder for Manipulating Bone Plate

ABSTRACT

A plate holder is provided to facilitate percutaneous introduction of a bone plate, positioning of the plate on a bone surface, and stabilizing the plate while a fastener is inserted through the plate into the bone. The plate holder includes a proximal handle, a distal mount, and an arm extending between the handle and the mount. The mount includes a first portion which seats within a slot on the shaft of a plate, and a second portion at which the shaft is coupled and which includes a tapered proximal side. A set screw hole is provided through the first and second portions, and a set screw is provided therein. When the first portion is seated in a compression slot of a plate and the set screw is driven to seat, the set screw locks the mount to the plate.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a continuation of U.S. Ser. No. 11/948,277, filedNov. 30, 2007, which is hereby incorporated by reference herein in itsentirety.

BACKGROUND OF THE INVENTION

1. Field of the Invention

This invention relates broadly to surgical devices and methods for theinternal fixation of fractured bones, and more particularly to boneplates, fasteners and tools therefor.

2. State of the Art

Fractures of the distal tibia include tibial plafond (or pilon)fractures and ankle fractures. These “high energy” fractures aretypically caused by axial loading of the ankle joint, due to falls,motor vehicle accidents and sports. The more common ankle fractures areusually repaired with screw fixation. However, as with any kind ofintra-articular fracture, distal tibial fractures are notoriouslydifficult to treat and are associated with a high complication rate.

Tibial plafond fractures are relatively uncommon (less than one percentof all fractures). Still, several thousands of people suffer annually.The type of fracture depends on the degree of comminution anddisplacement. Treatments of plafond fractures include external fixation,plating and nailing.

The same four basic principles for internal fixation apply to the distaltibia fracture as for any other bone fracture. These principles areproper anatomic reduction, stable fixation, preservation of blood supplyand early, active mobilization. Before plating the distal tibia,surgeons usually wait several days after the injury was incurred toallow the soft tissues to heal and the swelling to decrease. Normallythey will plate the distal fibula immediately if it is also fractured.After plating the distal tibia, weight bearing is normally not allowedfor several days.

Currently there is some controversy among orthopedic surgeons concerningthe management of tibial plafond fractures as to whether to use internalplating or external fixation. The trend in recent years has shifted toexternal fixation due to complications associated with plating. Majorcomplications include skin sloughing and infection. These relate to thesignificant soft tissue injury associated with the fracture. Other lesscommon complications include non-union, malunion, osteoarthritis andarthrodesis.

Current plates have been developed to try to reverse that trend. Theplates include Synthes LCP Anterolateral and Medial Distal Tibia Plates3.5, Smith & Nephew Peri-Loc Anterolateral and Medial Tibia LockingPlates, and Zimmer Periarticular Distal Tibia Locking Plates. Thecurrent plates are made of stainless steel. While the plates arepre-contoured for a non-specific bone, the systems are provided withbending tools that can be extended through the holes of a respectiveplate or gripped pliers that externally hold the plate to effectadditional bending of the plate. However, such bending must be done withthe plate off the bone in a manner in which it is difficult toapproximate the shape of the plate to a specific bone withoutsignificant trial and error. In addition, the medial plates of currentdistal tibia fixation systems have limited support for the subchondralbone of the articular surface. Moreover, any such support is either at apre-determined fixed angle using fixed angle screws in threaded holes orvariable angle and under compression. Where surgeons want to use adistal tibia plating system with a fixed angle construct to support thefracture, fixed angle constructs do not conform to the anatomy or havethe required strength to support distal tibia fractures. Thus, theseplate systems are unacceptable in their limitations.

SUMMARY OF THE INVENTION

A distal tibia plating system according to the invention providesimprovements in internal fixation of distal tibia fractures. The platingsystem includes an anterolateral plate and a medial plate. Each of theplates include a proximal shaft portion and a distal head portion. Thehead portion is provided with a plurality of threaded first holes and anon-threaded second hole. Each threaded first hole is configured forreceiving at least one of a plurality of fastener types and ispreferably chamfered to permit the head of the fastener to seat low inthe hole. Each of the fastener holes is preferably provided with apre-assembled drill guide that is adapted to guide a drill into bone inaxial alignment with the fastener hole and optionally for use with onemember of a pair of bending instruments.

The anterolateral plate is a low profile plate including a shaftdefining a longitudinal axis and a laterally extending distal head. Theshaft includes both threaded first fastener holes and compression slotsalong its length. The head includes a first row of four threadedfastener holes arranged transversely to the longitudinal axis, anon-threaded compression screw hole, and a plurality of distal tabs.Each tab includes a ring with a single threaded fastener hole and abridge that couples the ring to the distal end of the plate. The hole ineach tab is not necessarily chamfered, but the holes in the tabs arecapable of receiving the same fasteners as the first row of threadedfastener holes. The holes in the tabs are aligned to define a second rowof threaded holes. The first and second rows of threaded holes areapproximately parallel and the axes of the threaded holes of the firstrow are staggered with respect to the axes of the threaded holes of thesecond row. The tabs are preferentially oriented such that the axes ofthreaded holes of the first row converge and pass between the axes ofthe threaded holes of the second row, with fasteners insertedtherethrough thereby forming a load-bearing scaffold to support thearticular surface of the distal tibia. The bridge of each tab isconfigured to bend preferentially in a desired direction, such that anaxis of a fastener hole of a tab will not intersect the axis of afastener hole in the first row of the distal head portion. In thismanner, one or more of the tabs can be easily reconfigured relative tothe remainder of the plate, e.g., to capture the distal rim of thetibia, to capture a specific bone fragment or buttress and support adesired area, while the plate is on the bone. This is performed whilethe plate is either on or off the bone, by coupling the bendinginstruments to the drill guides and applying a relative force to bendingthe tabs about the bridges. A tab may also be easily removed by usingthe bending tools to reverse bend the tab until a clean fracture of thebridge element is effected.

The medial plate is a low profile plate including a shaft and arelatively enlarged distal head. The shaft includes both threadedfastener holes and compression slots along its length. The most distalslot includes a distal undercut. The head includes preferably seventhreaded fastener holes having preferably parallel axes, and preferablyarranged in two parallel proximal-distal rows of three and a final holelocated along the longitudinal axis of the plate between the two rows.At the distal end of the head, the head includes an extension providedwith a non-threaded, non-circular hole.

Each of the plates further includes fixed angle K-wire alignment holesto receive K-wires for provisional fixation of bone fragments and forfluoroscopic confirmation of the location of the plate. K-wires arepreferably provided in the system for use with the plates.

A plate holder is also provided which couples to the plates to maneuverthe plates subcutaneously through a minimally invasive surgicalincision. The plate holder includes a proximal handle, a distal mount,and an arm extending between the handle and the mount. The mountincludes a first portion which seats within a slot on the shaft ofeither plate, and a second portion at which the shaft is coupled andwhich includes a tapered proximal side. A set screw hole is providedthrough the first and second portions, and a set screw is providedtherein. When the first portion is seated in a compression slot of aplate shaft and the set screw is driven to seat, the set screw locks themount to the plate shaft. The arm of the plate holder is contoured toseat closely to the head of the plate, but to clear the drill guides inthe head portion of the plates. The plate holding tool facilitatespercutaneous introduction of the plate, positioning of the plate on thebone surface and holding the plate while the first fastener is inserted.

Each fastener includes a shank portion for engagement into the bone,wherein the shank portion may have one of a cortical thread, acancellous thread, a non-threaded portion and combinations thereof. Thehead portion of the fastener may have one of a fixed angle locking head,a non-locking compression head and a multidirectional locking head.

In view of the above, the system facilitates subchondral support of thearticular surface so that plate shares the load with bone duringhealing. The system also facilitates bone targeting and contouring ofthe plates to the bone so that intra-articular fragments can be capturedand fixated. The system accomplishes this in a manner that is lowprofile to minimize soft tissue trauma and patient discomfort.

Additional objects and advantages of the invention will become apparentto those skilled in the art upon reference to the detailed descriptiontaken in conjunction with the provided figures.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a top perspective view of an anterolateral plate of the distaltibia system of the invention.

FIG. 2 is a bottom perspective view of the anterolateral plate of FIG.1.

FIG. 3 is a transparent posterior view of the distal tibia with theanterolateral plate of FIG. 1 attached thereto by a plurality offasteners.

FIG. 4 is a top perspective view of the anterolateral plate of FIG. 1shown with drill guides attached thereto.

FIG. 5 is a perspective view of another embodiment of an anterolateralplate the distal tibia system of the invention, shown with drill guidesand bending tools.

FIG. 6 is an enlarged section view illustrating the structure of thedistal head of the anterolateral plate and the attachment of the bendingtools to the guides.

FIG. 7 is a top perspective view of a medial plate of the distal tibiaplating system of the invention.

FIG. 8 is a bottom perspective view of the medial plate of FIG. 7.

FIG. 9 is an enlarged top distal perspective distal view of medialplate, shown with drill guides attached thereto.

FIG. 10 is a transparent medial view of the distal tibia with the medialplate of FIG. 7 attached thereto by a plurality of fasteners.

FIG. 11 is a transparent posterior view of the distal tibia with themedial plate of FIG. 7 attached thereto by a plurality of fasteners.

FIG. 12 is a top perspective view of drill guide for use with the distaltibia plating system of the invention.

FIG. 13 is a side elevation of the drill of FIG. 12.

FIG. 14 is a perspective of a plate holder according to the invention.

FIG. 15 is an enlarged distal end broken view of the plate holder ofFIG. 14.

FIG. 16 is an anterolateral view of the anterolateral plate and plateholder assembly.

FIG. 17 is a distal perspective view of the assembly of FIG. 16.

FIG. 18 is section view through the longitudinal axis of theanterolateral plate of the assembly of FIG. 16.

FIG. 19 is an enlarged section view through the coupling of the plateholder to the anterolateral plate.

FIG. 20 is a medial view of the medial plate and plate holder assembly.

FIG. 21 is a distal perspective view of the assembly of FIG. 20.

FIG. 22 is section view through the longitudinal axis of the medialplate of the assembly of FIG. 20.

FIG. 23 is an enlarged section view through the coupling of the plateholder to the medial plate.

FIG. 24 is side elevation view of a fixed angle locking cortical screwfor use with the bone plates of the distal tibia system of theinvention.

FIG. 25 is side elevation view of a fixed angle locking cancellous screwfor use with the bone plates of the distal tibia system of theinvention.

FIG. 26 is perspective view of a multidirectional locking screw for usewith the bone plates of the distal tibia system of the invention.

FIG. 27 is side elevation view of a multidirectional compressionfastener for use with the bone plates of the distal tibia system of theinvention.

DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

The distal tibia plating system according to the invention includes ananterolateral plate 10 (FIGS. 1-6), a medial plate 110 (FIGS. 7-11),drill guides 200 (FIG. 12-13), bending tools 300 (FIGS. 5-6), a plateholder 400 (FIGS. 14-23), fasteners 500, 600, 700, 800 (FIGS. 24-27),and K-wires, as discussed below.

Anterolateral Plate

Turning now to FIGS. 1 and 2, the anterolateral plate 10 of the distaltibia plating system according to the invention is shown. Theanterolateral plate 10 includes a shaft 12 with a longitudinal axis 14,and a distal head 16, and a lower bone contacting surface 18 and anopposite upper surface 20.

The shaft 12 is twisted about the longitudinal axis 14 to match theanterolateral bone surface of the distal tibia. The shaft 12 has a width22 of between approximately 11 mm-12.2 mm to minimize the profile of theshaft. The shaft 12 has both threaded fastener holes 24 and elongatecompression slots 26 longitudinally arranged along its length. The shaft12 is provided with a preferably alternating arrangement of the threadedfastener holes 24 and slots 26. The number of threaded fastener holes 24and compression slots 26 is generally dictated by the length of theshaft 12 which can vary depending on the length of the fracture beingtreated and the stability required. It is preferred that a threadedfastener hole 24 be provided at the proximal end of the plate. Atcertain plate lengths, this may result in the plate having twoconsecutive threaded fastener holes 24 at the proximal end (see, e.g.,plate 10 a in FIG. 5). The threaded fastener holes 24 are preferablytriple lead tapered holes, and chamfered at 28 to permit the head of afastener, described below, to seat lower in the plate 10. The proximalend 30 of the shaft is tapered in width to facilitate percutaneousminimally invasive insertion of the plate.

The distal head 16 widens relative to the shaft 12 to transition into alateral extension 32. The head 16 is preferably provided in sizes ofapproximately 33.5 to 38.5 mm in width, depending on anatomicalconsiderations, to provide sufficient support in a minimized profile.The lower surface 18 of the head 16 is preferably curved in themedial-lateral direction to wrap around the distal tibia. The head 16includes a non-threaded compression screw hole 34 and a first row ofpreferably four threaded fastener holes 36 having the same threadstructure as holes 24. A plurality of distal tabs 38 (preferably two orthree tabs) are coupled to the distal head. Each tab has a threaded hole40 with the same thread structure as holes 24 and 36. Holes 40 aretogether aligned to define a second row of threaded fastener holes. Thefirst and second rows of threaded holes 36, 40 are approximatelyparallel and the threaded holes 40 of the second row are staggered(transverse to the longitudinal axis 14) with respect to the threadedholes 36 of the first row. The axial arrangement of the first and secondrows is such that thread axes 42 through the threaded holes of thesecond row converge in a proximal-distal direction below the bonecontacting surface 18 of the plate relative to the thread axes 44through the threaded holes of the first row, and that such thread axes42 through the second row pass between the thread axes 44 through thefirst row. Referring to FIG. 3, this arrangement of thread axes allowsfasteners 500 (generally, but any of the fixed angle fasteners discussedherein) inserted along the thread axes 42, 44 to form a load-bearingscaffold to support the articular surface 46 of the distal tibia 48against the talus of the foot. The threaded holes in the first row arepreferably chamfered so that the head 502 of fasteners 500 can seat lowin the plate 10. As discussed further below, the tabs 38 are of athinner construction than the remainder of the head 16 of the plate. Thethreaded holes 40 in the tabs 38 are preferably not chamfered so thatthe tabs have sufficient structural support to engage a selectedfastener.

Referring to FIG. 4, each of the threaded fastener holes can be providedwith a pre-assembled drill guide 200, described in more detail belowwith respect to FIGS. 12 and 13, that is adapted to guide a drill intobone in axial alignment with the fastener hole. Referring to FIGS. 5 and6, each drill guides 200 is adapted to couple relative to one member ofa pair of bending tools 300 to re-orient the configuration of the tabsby the surgeon, also described in more detail below. It is preferablethat each such fastener hole 40 in the second row be provided with adrill guide 200, and that the other fastener holes optionally beprovided with such drill guides.

Referring to FIGS. 1-3 and 6, each distal tab 38 is ring-shaped and isconnected to the distal end of the head 16 of the plate 10 with a bridge50. The tabs 38 are preferentially bendable to customize the loadbearing support of the articular surface 46 of the distal tibia 48. Thebridge 50 of each tab 38 is configured to bend preferentially inrotation about the y-axis. To that end, each bridge 50 preferably has arectangular cross-section, with width greater than thickness. Inaddition, the bridges may include a lower recess 52 in the widthwisedirection. Then if bent, the new thread axis 42 of a fastener hole 40will not intersect the thread axis 44 of a threaded fastener hole 36 ofthe first row in the head portion. To effect bending, the bending tools300 are fit over (as shown) or into two adjacent drill guides 200, onelocated in a tab 38 and one located in a thread hole 36 of the firstrow. Force is applied to the proximal ends of the bending tools 300 toeffect bending of the tab 38 relative to the head portion 16 of theplate 10. Thus, one or more of the tabs 38 can be easily reconfiguredrelative to the of the plate, e.g., to capture the distal rim of thetibia, to capture a specific bone fragment or buttress and support adesired area. Tab bending may easily be effected while the plate is onthe bone. Further, by designing the area of the tab 38 around thefastener hole 40 thicker than the bridge 50, it is ensured that the hole40 and threads thereof are not deformed when bending a tab 38 to adesired orientation. Moreover, the lower recess 52 also facilitatesremoving a tab 50 with the bending tools 300 by reverse bending the tab38 until a clean fracture of the bridge 50 is effected. The tabs 38 arepurposefully designed to fracture upon application of 20-25 in-lb force,i.e., by bending each of tabs 38 down about 30 degrees and back up about30 degrees.

The anterolateral plate includes K-wire alignment holes 56, 58, 60 thatreceive K-wires for provisional fixation of bone fragments and forfluoroscopic confirmation of the location of the plate. First alignmentholes 56 are preferably provided in the head portion of the platebetween the threaded holes 38 of the first row, a second alignment hole58 is provided between the first row of threaded holes 38 and thecompression hole 34, and a third alignment holes 60 is provided at theproximal end 30 of the plate 10. Each K-wire alignment hole preferablyprovides fixed angle alignment to a K-wire inserted therethrough.K-wires (not shown) are preferably provided with the system for use withthe anterolateral plate 10, as well as the medial plate 110, discussedbelow.

Medial Plate

Referring to FIGS. 7 through 9, the medial plate 110 includes a shaft112 with a longitudinal axis 114 and a relatively broader distal head116. The shaft 112 has a shallow radius of curvature transverse to thelongitudinal axis. This shallow radius enable the shaft to have athickness that is approximately 25 percent thinner than competitiveplates. The shaft 112 includes an arrangement of both threaded fastenerholes 124 and compression slots 126, along its length, similar to theanterolateral plate 10. The threaded fastener holes 124 are preferablytriple lead tapered thread holes. The proximal end 130 of the plate mayinclude consecutive threaded fastener holes. The most distal slot 128 aincludes a peripheral undercut 133 a, discussed in more detail below.

The head 116 of the plate 110 includes preferably seven threadedfastener holes 136 having the same hole and thread structure as holes124. The holes 136 preferably parallel axes, and preferably arranged intwo substantially parallel proximal-distal rows 135, 137 of three and acentral hole 136 a located between the two rows. At the distal end ofthe head, an extension 139 is provided with a non-threaded, non-circularhole 141 which can be used to direct a compression screw along axis 143towards the thread axis 145 of the central hole 136 a (FIG. 11). Each ofthe threaded holes is preferably of the same size and structure as thethreaded holes in the anterolateral plate 10. In addition, each of thethreaded holes in at least the head 116 is preferably provided with adrill guide 200 for guiding a drill. The drill guide 200 is described inmore detail below with respect to FIGS. 12 and 13.

A first K-wire alignment hole 156 is provided between the central hole136 a and the non-circular hole 141 and a second K-wire alignment hole160 is provided at the proximal end 130 of the shaft 112 to facilitatealignment and temporary positioning of the plate on the bone. FIGS. 10and 11 show the medial plate implanted on the medial side 160 of thedistal tibia 48.

Each of the plates 10, 110 of the present system may be formed from anyone of numerous materials known in the art, including a stainless steel,a titanium and a titanium alloy such as Ti-6A1-4V. More preferably, eachof the plates is preferably machined from a solid round bar ofTi-6A1-4V-ELI in the fully annealed condition. Each plate is machined toits respective anatomical shape to ensure minimal work hardening. Aftermachining, the parts are polished and anodized. The resulting platematerial is fully ‘soft’ and permits the ability to bend the plate atthe tabs or relative to the longitudinal axis without fracture of theplate. In general, each of the plates described herein is significantlythinner than currently available plates for the same types of fractures,yet still has the appropriate rigidity for internal fixation of thefractured bone.

Drill Guides

Referring to FIGS. 12 and 13, a drill guide 200 having a cylindricalbody 202, a proximal end 204, and a distal end 206 is shown. The drillguide 200 also has an axis 205 and a longitudinal bore 208 sized forguiding a conventional bone drill. A plurality of internal driveelements 210 are formed in bore 208 near proximal end 204. In thisembodiment, the plurality of internal drive elements 210 include sixinternal drive elements 210 for receiving the hexagonally shaped distaltip of a conventional bone screw driver tool, although otherconfigurations and quantities of internal drive elements 210 arepossible.

The distal end 208 of the drill guide 200 is provided with a taperedthreaded portion 212 configured for threaded engagement with a taperedthreaded hole of both the anterolateral or medial bone plates, such thataxis 205 is colinear with the axis of the tapered threaded hole.

The cylindrical body 202 preferably has a length of approximately 9 mmfrom the proximal until the start of the threaded portion 212, and anexternal diameter of approximately 5 mm.

The bone plates 10, 110 may be provided to the surgeon with each taperedthreaded hole of the bone plate already preassembled with drill guide(or guides preassembled in selected threaded holes), so that it is notnecessary for the surgeon or an assistant to attach a drill guide toeach hole during the procedure as is normally done for conventional boneplating systems. In this way, the surgeon may quickly drill several boneholes, such that the axis of each hole is in perfect alignment with thehole thread axis. The surgeon may then remove the drill guide using thehexagonally tipped driver and insert a locking bone fastener, such thatthe threaded head of the locking fastener easily engages with thethreaded hole. The pre-assembly of a drill guide to a bone plate isdescribed in co-owned U.S. Pub. No. 20060149250A1, and the use of suchdrill guide for bending a plate is described in co-owned U.S. Pub. No.20060161158A1, 20070233111A1, and 20070233112A1, all of which are herebyincorporated by reference herein in their entireties.

The drill guides are preferably color coded, so to provide a visual cueto the surgeon and staff as to whether a plate is for the left or rightbone. For example, guides may be color green for left application andred for right application.

Plate Holder

Referring to FIGS. 14 and 15, a plate holder 400 is also provided whichcan be coupled to the plates 10, 110 to maneuver the platessubcutaneously through a minimally invasive surgical incision. The plateholder 400 includes a handle 402, a mount 404, and an arm 406 extendingbetween the handle 402 and the mount 404. The mount 404 includes a firstlower portion 406 with a lip 408 which seats within a distalmostcompression slot on the shaft of either plate, and a second upperportion 410 at which the arm is permanently secured. The second portion410 includes a tapered upper proximal side 412 to ease insertion undersoft tissue. A set screw hole 414 is provided through the first andsecond portions, and a set screw 416 is provided therein. When the firstportion 406 is seated in a slot of a plate shaft and the set screw 416is driven to seat, the set screw drives the first portion 406 intocompression with the plate shaft to lock the holder 400 and plate intoan assembly. The arm 406 of the plate holder 400 is contoured to seatclosely to the head of the respective plate, but to clear the drillguides 200 in the head portion of the plates. The plate holderfacilitates positioning of the plate on the bone surface and holding theplate while the first fastener is inserted.

More particularly, referring to FIGS. 16 through 19, the plate holder400 is shown coupled to the anterolateral plate 10. In the anteriorview, the proximal portion 406 a of the arm 406 (adjacent the handle) ofthe holder 400 extends in the same plane as the longitudinal axis 14 ofthe shaft 12 of the plate 10. The distal portion 406 b of the arm(adjacent the plate) is contoured about the head so as to not interferewith the drill guides 200 but to extend close to the plate (see verticaldimension in FIG. 18) to limit interference with soft tissue duringplate insertion. When the mount 404 is coupled relative to the plate,the lip 408 does not extend under the compression slot 26 of the plate10. The set screw 416 forces a distal wall 418 of the first portion 406against a wall of the slot to engage the holder 400 relative to theplate. The holder 400 may be released from the plate by loosening theset screw. The angle of the set screw hole 414 and set screw 416 isapproximately 35° relative to the axis of the plate so as to effectappropriate compression and be easily accessed via a driver even oncethe plate is at the implantation site.

Referring to FIGS. 20 through 23, the same plate holder 400 is shownattached to the medial plate 110. The proximal end 406 a of the arm 406is also in-plane with the shaft axis 114, and the distal end 406 b iscontoured about the head 116 so as to not interfere with drill guides200 and to maintain a low profile to the plate. The distal compressionslot 126 a of the medial plate includes an undercut 133 a. When thefirst portion of the mount is inserted into the slot 126 a, the lip 408engages at the undercut 133 a to further secure the holder to the plate110.

Plate holders 400 may be color coded for left and right plates (e.g.,green-left; right-right) and correspond in color to the drill guides tofacilitate engagement to the correct plate.

Fasteners

Each of the threaded holes in both plates 10, 110, whether in the heador shaft portions of the anterolateral or medial plate can all receivethe same fastener types. Thus, the fasteners in the system areinterchangeable between the plates. Generally, the fasteners includes ashank portion for engagement into the bone, wherein the shank portionmay have one of a cortical thread, a cancellous thread, a non-threadedportion and combinations thereof. Each fastener type further includes ahead portion for engagement with the fastener hole, wherein the headportion may have one of a fixed angle locking head, a non-lockingcompression head and a multidirectional locking head.

FIGS. 24 through 27 show four embodiments of fixed angle bone fasteners.FIG. 24 is a side view of a fixed angle locking screw 500, whichincludes a tapered threaded head 502 having a driver recess (not shown),and a threaded shaft 504. The threads on the shaft having a pitchadapted for engaging cortical bone. Screw 500 may be inserted and lockedinto a tapered, threaded hole of a bone plate at a fixed anglepredetermined by the hole thread axis. FIG. 25 is a side view of a fixedangle locking screw 600, substantially similar to screw 500, but whereinthe threads of shaft 604 have a relatively larger pitch adapted forengaging cancellous bone.

FIG. 26 is a side view of a multidirectional locking screw 700. Screw700 includes a head 702 with a square drive recess 706, and a shaft 704.The screw 700 may be locked into either plate, such that a screw axisforms an angle in the range of 0-15 degrees with the thread axis of thehole. Screw 700 may be formed from a cobalt-chrome alloy that issignificantly harder than the plate material, which may be a titaniumalloy. Such a multidirectional locking screw is described in detail inU.S. Pub. No. 20070088360A1, which is hereby incorporated by referenceherein in its entirety.

For the fastener embodiments 500, 600, and 700, the shaft alternativelybe smooth along all or a portion of its length.

FIG. 27 is a multidirectional compression fastener 800, also calledscrew 800. Screw 800 includes a threaded shaft 804 and a distal tip 808.Screw 800 further includes a head 802 having a proximal face 810 with asquare drive recess, although other drive recess configurations arepossible. Head 802 includes a smooth, frustoconical portion 812 having asmall diameter end 840 attached to body 804 and a large diameter end 842forming a peripheral edge 814 of proximal face 810. Frustoconicalportion 812 has an included angle (indicated by A) centered on a screwaxis 820. Peripheral edge 814 may have an external radius. Threads ofscrew shaft 804 may be either cancellous or cortical, and may optionallybe formed along only a portion of the length of the shaft 804.

As will be appreciated by those skilled in the art, the present systemdescribed herein provides to a surgeon the advantageous option to useany one of a standard compression screw (no shown, but for use throughnon threaded holes), a fixed angle locking screw (screws 500, 600), amultidirectional locking screw (screw 700), or a multidirectionalcompression screw (screw 800) in the same tapered threaded hole, whichis included in both of the bone plates described herein. In addition,each of screws 600, 600, 700, 800 is insertable into the taperedthreaded hole, such that the screw head is minimally proud relative tothe top surface of the bone plate, thereby minimizing patient discomfortand complications due to soft tissue irritation.

In view of the above, the system facilitates diaphyseal, metaphyseal,and subchondral support of the articular surface of the distal tibia sothat plate shares the load with bone during healing. The system alsofacilitates bone targeting and contouring of the plates to the bone sothat intra-articular fragments can be captured and fixated. The systemaccomplishes this in a manner that is low profile to minimize softtissue trauma and patient discomfort.

There have been described and illustrated herein several embodiments ofplates of a distal tibia plating system. While particular embodiments ofthe invention have been described, it is not intended that the inventionbe limited thereto, as it is intended that the invention be as broad inscope as the art will allow and that the specification be read likewise.Where the terms ‘approximate’, ‘approximately’ or ‘substantially’ areused herein, such terms are to be defined as ±20 percent of a givennumber, amount, or relative position or location, as determined bycontext. It will therefore be appreciated by those skilled in the artthat yet other modifications could be made to the provided inventionwithout deviating from its spirit and scope as claimed.

1. A plate holder for manipulating a bone plate having an upper surface,a lower surface, and an elongate compression slot extending between theupper and lower surfaces in which a screw is intended to be received,comprising: a) a handle; b) a shaft-like arm extending from the handle,the arm having a first end coupled to the handle and a second end; c) amount coupled at the second end of the arm at a first location, themount including a locking portion extendable into the compression slotand having a lip at a lower end thereof, a set screw hole laterallyoffset relative to the first location, the set screw hole having anentry for receiving a set screw on a same side as the lip and threadsfor engagement with a set screw; and d) the set screw threadedly engagedin the set screw hole, the set screw having a head at which the setscrew is rotated within the set screw hole with a driver, wherein whenthe locking portion is inserted into the compression slot and the setscrew is advanced into the set screw hole, advancement of the set screwforces the lip into engagement relative to the bone plate to lock theplate holder relative to the bone plate so that the plate holder can beused to manipulate the bone plate.
 2. A plate holder according to claim1, wherein: the mount includes a taper on its upper surface on a sideopposite the entry of the set screw hole.
 3. A plate holder according toclaim 1, wherein: the arm includes a straight first portion extendingfrom the handle, and a second portion extending to the mount andcontoured to maintain a low profile relative to the upper surface of thebone plate.
 4. A plate holder according to claim 1, wherein: whenlocking portion of the mount is receiving within the compression slot ofthe bone plate, the threads of the set screw hole define an axis at anoblique angle relative to the upper surface of the bone plate.
 5. Aplate holder for manipulating a bone plate having a compression slot,comprising: a) a handle; b) a plate mount; and c) an arm between thehandle and the mount, the arm including a straight portion, the mountincluding a first portion extendable into the compression slot and asecond portion extending thereabove, a threaded set screw hole beingdefined at an oblique angle through the first and second portions, and aset screw provided in the set screw hole, the first portion includes alower lip at a first side, and the second portion includes a taper at asecond side opposite the first side.
 6. A plate and plate holder system,comprising: a) a bone plate having an upper surface, a lower surface,and at least one elongate compression slot extending between the upperand lower surfaces, each compression slot adapted to receive acompression screw to couple the bone plate relative to a bone; b) aplate holder adapted to be coupled to one of the compression slots, theplate holder including a handle, a plate mount, and an arm extendingbetween the handle and the plate mount, the mount including a firstportion extendable into the one of the compression slots and a secondportion extending thereabove, a threaded set screw hole being definedthrough the first and second portions having an entry and an exit, and aset screw provided in the set screw hole and having a shaft portion atleast partially advanceable through the exit, the arm including a firstlength adjacent the handle and a second length adjacent the mount,wherein when the plate holder is coupled to the medial plate, the firstlength extends in a common plane with the longitudinal axis of themedial plate, wherein the set screw hole is oriented such that when thefirst portion is inserted into the compression slot and the set screw isrotated within the set screw hole such that the shaft portion of the setscrew advances through the exit, the first portion is forced within thecompression slot in a direction opposite a location of contact by theshaft portion of the set screw against the bone plate surrounding thecompression slot to cause the mount to be secured to the bone plate. 7.A plate holder according to claim 6, wherein: the mount includes a taperon its upper surface on a side opposite the entry of the set screw hole.8. A plate holder according to claim 6, wherein: the arm includes astraight first portion extending from the handle, and a second portionextending to the mount and contoured to maintain a low profile relativeto the upper surface of the bone plate.
 9. A plate holder according toclaim 1, wherein: when the first portion of the mount is receivingwithin the compression slot of the bone plate, the threads of the setscrew hole define an axis at an oblique angle relative to the uppersurface of the bone plate.